By Karen R. Koenig, LICSW, M.Ed.
Many of our clients creep slowly along toward psychological health like caterpillars, inching forward, stopping, curling into themselves, then unfurling and continuing on. We are grateful when there is progress, patient when there is not. A few clients charge ahead with their eye on the prize and never look back. Them we cheer on — and eventually off our caseload.
But what of the client who virtually makes no changes after years of therapy with us (and often a slew of predecessors), the client who is simply too entrenched, terrified or trapped for wishes to overcome fears? I am not talking about the client who has gone as far as he or she can therapeutically go, with whom we may rejoice at the progress that has been made and acknowledge an impasse, a standstill. Perhaps, like hair and skin products, therapists need to be switched every so often that we don’t lose our cleansing, healing power. Or, to mix metaphors, perhaps we may sometimes need to retire ourselves to the sidelines and give over a particular game to fresher blood.
Neither am I talking about the client who does a piece of work, then withdraws from therapy only to resurface months or years later in the same or similar predicament — sabotaging yet another job or relationship, shackled to yet another addiction. Nor the client who takes a giant step forward and gets a job, establishes a truce with a parent, returns to college, joins AA, leaves an abusive marriage, then sharply regresses or relapses. Or the severely traumatized client for whom months or even years of therapy are needed to establish even the rudiments of a therapeutic relationship. Nor the client in mandatory treatment who has made it clear from the get go that he or she is just marking time.
The client I have in mind is one who lacks the courage, capacity, and readiness for major advancement, who is so fragile and bereft of intrapsychic resources that the therapeutic relation-ship itself becomes both a cradle and a coffin. The client who can neither let go of therapy nor hold onto it long enough to achieve significant progress, who constantly feels therapied out because they’ve never allowed themselves to feel truly therapied in, who is either crowding the net or way off the court. The one who drops out of therapy abruptly for weeks or months at a time and when chased down is brimming with tearful apology, the one for whom therapy is like a hammer, wielding both the hope of creation and the threat of extinction.
This dilemma is more often than not lifted out of our hands by insurance companies. But if payment continues to flow from the insurer, the client or the government, what should be our treatment position be with a client who cannot seem to stop spinning his wheels, chasing her tail, marching in place? What is the social worker’s moral, ethical, and humane obligation to clients who may be going nowhere with us but who may find themselves somewhere perilous without us?
If we persist in working with these going-nowhere clients without flagging their lack of progress, we are derelict in our duty to mirror reality. It may be called talk therapy, but we know we are constantly priming the pump for eventual, effective action. On the other hand, if we consistently challenge their stuck-ness, we run the risk of spending session after session getting sucked down into the client’s quicksand, fruitlessly debating issues such as missed sessions, chronic lateness, faulty consistency, and half-hearted commitment.
Sometimes we may gently inform these clients that we don’t think we are helping them and/or that they are not ready to change. We think we are setting them free, unshackling them from the burden of change, but often our well-intended clinical good turn is merely experienced as a stiff shove toward free-fall. They feel rejected, abandoned, pitifully unable to please us, a shameful disappointment to themselves. We hope that stating the obvious — that a client is not ready to change — will move them to flip-flop to the other end of their ambivalence and help them muster their resources. But what if there are no or few resources to muster? Ironically, on some level clients often know this long before we do. That is why they are so heartsick, hopeless and paralyzed, so bereft at being bereft. Sadly, the very best they can do is to alternately cling to us and push us away.
So what do we do when they can’t live with us and they won’t live without us? Are we taking their (or someone’s) money under false pretenses when we do little more than prop up a client? What if we are the glue that holds their broken pieces together and life may not be long enough for them to produce their own self-adhesion? Can we sleep peacefully if we allow clients to slip in and out of treatment like ghost ships who need to moor themselves to our dock on occasion?
With these kinds of troubling, trouble-some clients, there is no easy, one-size-fits-all answer, but there are a few approaches which might keep us both — therapist and client alike — in the light.
First, we might step back from the relationship and see it for what it is and, perhaps more importantly, what it is not. An increasing and deepening attachment between the client and therapy might replace more conventional goals such as getting a job, learning to be assertive, separating from a parent, or managing depression more effectively. We might learn to expect, but not necessarily be satisfied, that therapy will in all likelihood be supportive (a term which seems to have been bumped out of our psychological lexicon by the current focus on ends over means) rather than progressive. We might view the relationship as one in which our ego will need to be lent over and over to this client for the forseeable future.
We might redefine the therapy as intermittent rather than ongoing, take the approach that less is more — the less pressure the client feels from us, the more he or she may feel in control of the relationship. As we well know, many clients who suffer early character disturbance are so frightened of being engulfed or abandoned that they are unable to make a consistent commitment to therapy, even after many years.
One avenue to pursue with in-again, out-again clients is to establish goals. What are their current goals? What were they when they entered therapy with us? Of course, the client may have no goals or be too confused or afraid to identify them, in which case working on how the client can continue to remain in therapy without dropping out may be the only worthwhile goal.
Most importantly, we need to deal with these most fragile clients on a case-by-case basis and keep all options open. We must address our often intense countertransference, including acute feelings of frustration, anger, helpless-ness and hopelessness. Supervision is often beneficial and comforting. If we are reflective and humane in working with these clients, we can at least feel proud that we have done our best, even as they are doing theirs.
FOCUS Newsletter - December 2000
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